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Concussion with Vestibular complications by the Vestibular.org

 Concussion article by the Vestibular.org

Concussion
When Recovery Is Complicated By Vestibuar Involvement
And How Vestibular Rehabilitation Can Help
By Nicole Miranda, PT, DPT
What happens to the brain and
vestibular system after concussion?
Concussion can occur under the following
conditions:
The head strikes a stationary
object. Common
examples include
a fall where the head hits the
ground or an object, or hitting the
head on an object during an auto
accident.
An object hits the head,
such as a ball or stick
during sports, or as a result
of human collision.
A quick
acceleration/deceleration of
the head with no contact to
any surface. This can occur
in dancers and gymnasts
due to rapid movement, or
during an auto accident
where there appears to be
no head trauma.
These events all cause quick
deceleration of the head and
shifting of delicate brain tissue
inside the skull. Rarely does an
accident of this nature occur in a
true head
on or forward/backward
direction. There is typically a
rotational force, as would occur if
one were struck on the right
struck on the right or
left side of the forehead. If the body
 is traveling forward or facing
forward in a still position, and a
force occurs off center, the brain sustains
a rotational sheer force, which causes
more trauma
brain structures and
therefore a more severe concussion.
Loss of consciousness and nausea at the
time of injury are signs that rotational
forces have occurred.
Current research on athletes shows that
nerve signals in the brain are disrupted
for 30 days after a single concussion, and
during this time frame people are more
likely to have her injury if engaged in
sport activities. This is because reaction
time and brain processing are not normal.
We are less likely to see something, like a
ball, coming toward the head during this
vulnerable period. If more than one
concussion occurs, the
symptoms are
typically worse and recovery time is
increased.
Trauma to the brain can result in
abnormal vestibular system functioning,
and the brain can receive abnormal
signals regarding the position and
movement of the head in space. When
vestibular information is inaccurate, the
brain most often relies on visual input to
stabilize the head on the body. This
means that the visual system becomes
the most reliable system to quickly
assess one’s position in space and to
remain balanced.
Relying upon vision
alone as the primary source of balance
often leads to fatigue and difficulty
performing routine daily activities.
Reliance on the visual system for balance
can result in eyestrain and tension
headaches. If the vestibular system is
delivering inaccurate information to the
brain about the head’s position in space,
the brain must rely on visual input and
joint sensors (proprioception) to feel the
body in space. Failure to effectively
compensate with the use of visual
references and being aware of the surface
on which one is sitting or standing results
in dizziness and a sense of instability.
Dizziness encourages a person to refrain
from moving the head, and leads to neck
stiffness and headaches. Presence of a
whiplash associated with the concussion
further complicates the diagnosis and
suddenly symptoms limit the ability to
participate in life activities.
HOW DO I KNOW IF I HAD A
CONCUSSION?
There is currently no diagnostic test for
the presence of a concussion. If there is
any suspicion of a concussion during
sporting activity, an athlete or child
should be removed from play to watch
and assess behavior, and in many states
medical clearance is necessary to legally
return to play. If a person develops signs
of neurological injury, such as repeated
vomiting, seizure activity, loss of
consciousness, unequal pupil size,
confusion or slurred speech, immediate
medical attention is necessary to rule out
serious brain trauma.  Apart from sports,
any mechanism of trauma to the head
and neck can result in concussion and
should be evaluated if symptoms are
present.
Concussion injury does not appear on any
routine brain scan such as CT or MRI, and
there is no diagnostic test for concussions
 A diagnosis of concussion is
made based on a group of symptoms that
can become immediately present or may
arise over weeks to months after injury.
Acute symptoms can be present for one to
symptoms can be present for one to two
weeks following the concussion,
and the most common recommendation
is to limit activities and rest the brain
with the anticipation of natural recovery.
Presence of three or more of the following
symptoms within four weeks of injury is
classified as Post Concussion Syndrome
Thinking/
Remembering
Physical
Emotional/
Mood
Sleep
Difficulty thinking clearly
Headache
Fuzzy or blurry
vision
Irritability
Sleeping more than
usual
Feeling slowed down
Nausea or vomiting
(early on)
Dizziness
Sadness
Sleeping
less than
usual
Difficulty concentrating
Sensitivity to noise
or light
Balance problems
More emotional
Trouble falling asleep
Difficulty remembering
new information
Feeling tired,
having no energy
Nervousness or
anxiety
www.cdc.gov/concussion/signs_symptoms.html
WHY DO SOME PEOPLE HAVE
Few to no symptoms, some people slowly
DEVELOP SYMPTOMS OVER
TIME AND OTHERS FEEL THEY
CANNOT FUNCTION AFTER
CONCUSSION?
It can be normal to have no symptoms
after a concussive event. In studies of
athletes, Almost all subjects are free of
symptoms by three days after the injury
while brain studies still show reduced
nerve signal transmission and risk of
injury for up to 30 days.
Other people feel normal for two to three
weeks, then have a steady headache,
dizziness or fatigue that at times are not
recognized as being caused by the
concussion. Fewer people have
immediate and more severe concussive
symptoms that last for prolonged time
frames.
We now know some response to
concussion can be influenced by genetics.
People who have a history of dementia or
Alzheimer’s disease in their family can be
more at risk for having a worse response
after concussion. This is because some
people have proteins (Tau) in the brain
that already place them at risk of
memory problems, which can be
aggravated by concussion. This results in
more cognitive difficulties
with memory, concentration and motivation
afterexperiencing a concussion..
Due to the forces involved in concussion,
it is very common to sustain a whiplash
injury that is often not diagnosed with the
concussion. As the head decelerates or
receives the force of an incoming
object,
the neck muscles are strained. The
effects of whiplash injury are not always
immediate and can appear
two to three weeks later with an
increasing number of tension headaches
and visual disturbances. Dizziness can also occur
related to neck strain. This delayed
increase in symptoms can interfere
greatly with school and work
performance.
Finally, many people have previous
conditions that make the brain’s response
to concussion more problematic. A prior
history of migraine headaches can lead to
complex migraines after
experiencing a concussion.
concussion. At times migraines can occur
without headache and produce only aura
 that feels like vertigo or dizziness lasting
for multiple hours or days. Failure
to recognize and treat migraine activity
can lead to prolonged symptoms and
places more stress on the brain, limiting
recovery.  A History of visual disturbances or
childhood sensory processing issues also
affects one’s response to concussion. For
example, if a person had difficulty with
distance vision or depth perception before
the injury, the brain adjusted to that problem.
. After an injury, the way in
which the brain compensated for the
visual problem may not work as well, and
the ability to focus on static objects or
following moving objects may cause
symptoms of dizziness,
as well as head pressure, head fog
and concentration problems.
 Likewise, if a prior history of
sensory integration problems and history
of motion sickness is present, concussion
can again cause increased difficulty for
the brain to process vestibular
information.
HOW DO SYMPTOMS OF
CONCUSSION AFFECT DAILY LIFE?
The concussion injury itself is ‘invisible’,
as headache, dizziness, head fog, eye
strain and fatigue are rarely perceived by
others. Thus, the disruption of the
brain’s ability to process sensory input
can result in extreme fatigue, frusteration
and emotional instability. In children,
this manifests as behavioral outbursts or
tantrums. Highly visual activities
overwhelm the brain, so crowded
environments (work, school, stores,
public events) can cause elevation of
symptoms or anxiety.
Work and school performance can suffer
as concentration and memory are
affected. Adjusting visual focus from
near and far can cause dizziness and
headache. In schools, looking from the
desk to PowerPoint presentations or too
boards in front of the classroom is
extremely challenging. Children and
adults alike report difficulty remembering
information and concentrating with
reduced accuracy in work performance.
Students have trouble completing
homework and adults arrive home from
work with extreme fatigue and lack of
energy to engage in family and household
activities.
Complex visual environments elevate
symptoms of headache, head pressure,
dizziness and imbalance, and can cause
anxiety. Over time people tend to
withdraw from outings and can become
depressed from the inability to perform
routine daily activities. Crowded places
are difficult to navigate because of the
movement of people and complex visual
background in the observers peripheral
vision. Thes visual distractions cause a
sese of imbalance and dizziness, often
with head pressure, that can lead to panic
attacks or avoidance of activity.
HOW CAN I BEST COPE WITH
Symptoms of concussion. ?
The best treatment for symptoms of a concussion is
assessment of vestibular function by a Physical Therapist..
A comprehensive vestibular
evaluation should include examination of
balance activities that involve the
vestibular, vision and proprioceptive
systems, which reveals how the brain
interprets movement of the body and
head relative to space and the visual
surround.  A cervical examination determine
if neck sprain or dizziness

Concussion
When Recovery Is Complicated By Vestibu
lar Involvement
And How Vestibular Rehabilitation Can Help
By Nicole Miranda, PT, DPT
What happens to the brain and
vestibular system after concussion?
Concussion can occur under the following
conditions:
The head strikes a stationary
object. Common
examples include
a fall where the head hits the
ground or an object, or hitting the
head on an object during an auto
accident.
An object hits the head,
such as a ball or stick
during sports, or as a result
of human collision.
A quick
acceleration/deceleration of the head with no  contact to
any surface. This can occur
in dancers and gymnasts
due to rapid movement, or
during an auto accident
where there appears to be
no head trauma.
These events all cause quick
deceleration of the head and
shifting of deli
cate brain tissue
inside the skull. Rarely does an
accident of this nature occur in a
true head on or forward/backward
direction. There is typically a
rotational force, as would occur if
one were struck on the right or
left side of the forehead. If the
body is traveling forward or facing
forward in a still position, and a
force occurs off center, the brain sustains
a rotational sheer force, which causes
more trauma
brain structures and
therefore a more severe concussion.
Loss of consciousness and nausea at the
time of injury are signs that rotational
forces have occurred.
Current research on athletes shows that
nerve signals in the brain are disrupted
for 30 days after a single concussion, and
during this time frame people are more
likely to have anot
her injury if engaged in
sport activities. This is because reaction
time and brain processing are not normal.
We are less likely to see something, like a
ball, coming toward the head during this
vulnerable period. If more than one
concussion occurs, the symptoms are
typically worse and recovery time is
increased.
Trauma to the brain can result in
abnormal vestibular system functioning,
and the brain can receive abnormal
signals regarding the position and
movement of the head in space. When
vestibular information is inaccurate, the
brain most often relies on visual input to
stabilize the head on the body. This
means that the visual system becomes
the most reliable system to quickly
assess one’s position in space and to
remain balanced.
Relying upon vision
alone as the primary source of balance
often leads to fatigue and difficulty
performing routine daily activities.
Reliance on the visual system for balance
can result in eyestrain and tension
headaches. If the vestibular system is
delivering inaccurate  information to  The brain about the head’s position in space,
the brain must rely on visual input and
joint sensors (proprioception) to feel the
body in space. Failure to effectively
compensate with the use of visual
use of visual
references and being aware of the surface
on which one is sitting or standing results
in dizziness and a sense of instability.
Dizziness encourages a person to refrain
from moving the head, and leads to neck
stiffness and headaches. Presence of a
whiplash associated with the concussion
further complicates the diagnosis and
complicates the diagnosis and
suddenly symptoms limit the ability to
participate in life activities.
HOW DO I KNOW IF I HAD A
CONCUSSION?
There is currently no diagnostic test for
the presence of a concussion. If there is
any suspicion of a concussion during
sporting activity, an athlete or child
should be removed from play to watch
and assess behavior, and in many states
medical clearance is necessary to legally
return to play. If a person develops signs
of neurological injury, such as repeated
vomiting,seizure activity, loss of
consciousness, unequal pupil size,
confusion or slurred speech, immediate
medical attention is necessary to rule out
serious brain trauma.
Apart from sports, any mechanism
of trauma to the head
and neck can result in concussion and
should be evaluated if symptoms are
present.
Concussion injury does not appear on any
routine brain scan such as CT or MRI, and
there is no diagnostic test for concussion
 A diagnosis of concussion is
made based on a group of symptoms that
can become immediately present or may arise
 over weeks to months after injury.
Acute symptoms can be present for one
to two weeks following the concussion,
and the most common recommendation
is to limit activities and rest the brain
with the anticipation of natural recovery
Presence of three or more of the following
symptoms within four weeks of injury is
classified as Post Concussion Syndrome.
Thinking/
Remembering
Physical
Emotional/
Mood
Sleep
Difficulty thinking clearly
Headache
Fuzzy or blurry
vision
Irri
tability
Sleeping more than
usual
Feeling slowed down
Nausea or vomiting
(early on)
Dizziness
Sadness
Sleeping
less than usual concentrating
Sensitivity to noise
or light
Balance problems
More emotional
Trouble falling asleep
Difficulty remembering
new information
Feeling tired,
having no energy
Nervousness or
anxiety, few to
no sumptoms, some people
slowly develop symptoms over
time and others feel they cannot
function after concussion?
It can be normal to have no symptoms
after a concussive event. In studies of
athletes, almost all subjects are free of
all symptoms by three days after injury
while brain studies
still show reduced
nerve signal transmission and risk of
injury for up to 30 days.
Other people feel normal for two to
three weeks, then have a steady increase in
headaches, dizziness or fatigue that at times at not
recognized as being caused by the
concussion.
Fewer people have
immediate and more severe concussive
symptoms that last for prolonged time
frames.
We now know some response to
concussion can be influenced by genetics.
People who have a history of dementia or
Alzheimer’s disease in their family can be
more at risk for having a worse response
after a concussion. This is because some
people have proteins (Tau) in the brain
that already place them at risk of
memory problems, which can be
aggravated by concussion. This results in
more cognitive difficulties
with memory,
concentration and motivation
after experiencing a concussion.
.
Due to the forces involved in concussion,
it is very common to sustain a whiplash
injury that is often not diagnosed with the
concussion. As the head decelerates or
receives the force of an incoming
object,
the neck muscles are strained. The
effects of whiplash injury are not always
immediate and can appear
two to three weeks later with an increasing number
of tension headaches and visual disturbances,
weeks later  Dizziness can also occur
related to neck strain. This delayed
increase in symptoms can interfere
greatly with school and work
performance.
Finally, many people have previous
conditions that make the brain’s response
to concussion more problematic. A prior
history of migraine headaches can lead to
complex migraines after
experiencing a concussion.
 At times migraines can occur
without headache and
produce only an
aura that feels like vertigo or dizziness
lasting, for multiple hours or days. Failure
to recognize and treat migraine activity
can lead to prolonged symptoms and
places more stress on the brain, limiting recovery.
A history of visual disturbances or
childhood sensory processing issues also
affects one’s response to concussion. For
example, if a person had difficulty with
distance vision or depth perception before
the injury, the brain adjusted to that problem.
brain adjusted. After an injury, the way in
which the brain compensated for the
visual problem may not work as well, and
the ability to focus on static objects or following
moving objects may cause symptoms of dizziness as well
as head pressure, head fog and concentration.
. Likewise, if a prior history of
sensory integration problems and history
of motion sickness is present, concussion
can again cause increased difficulty for
the brain to process vestibular
information.
HOW DO SYMPTOMS OF
CONCUSSION AFFECT DAILY LIFE?
The concussion injury itself is ‘invisible’,
as headache, dizziness, head fog, eye
strain and fatigue are rarely perceived by
others. Thus, the disruption of the
brain’s ability to process sensory input
can result in extre
me fatigue, frustration
and emotional instability. In children,
this manifests as behavioral outbursts or
tantrums. Highly visual activities
overwhelm the brain, so crowded
environments (work, school, stores,
public events) can cause elevation of
symptoms or anxiety.
Work and school performance can suffer
as concentration and memory are
affected. Adjusting visual focus from
near and far can cause dizziness and
headache. In schools, looking from the
desk to PowerPoint presentations or
order boards in front of the classroom
is extremely challenging. Children and
adults alike report difficulty remembering
information and concentrating with
reduced accuracy in work performance.
Students have trouble completing
homework and adults arrive home from
work with extreme fatigue and lack of
energy to engage in family and household
activities.
Complex visual environments elevate
symptoms of headache, head pressure,
dizziness and imbalance, and can cause
anxiety. Over time people tend to
withdraw from outings and can become
depressed from the inability to perform
routine daily activities. Crowded places
are difficult to navigate because of the
movement of people and complex visual
background in the observer’s perpheral vision
these visual distractions cause a sense of imbalance and
dizziness, often with head pressure that can ead to panic attacks
or avoidance of activity.
HOW CAN I BEST COPE WITH
Symptoms Of Concussion?
The best treatment for symptoms of
concussion involves an assessment of
Vestibular function by a Physical therapist..
A comprehensive vestibular
evaluation should include examination of
balance activities that involve the
vestibular, vision and proprioceptive
systems, which reveals how the brain
interprets movement of the body and
head relative to space and the visual
suround. A cervical examination
determines if neck sprain or dizziness.
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